Provider Demographics
NPI:1174942650
Name:PELLEGRINO, CAROLYN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-2606
Mailing Address - Country:US
Mailing Address - Phone:850-228-8139
Mailing Address - Fax:
Practice Address - Street 1:12875 CUMMING HWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115
Practice Address - Country:US
Practice Address - Phone:770-240-0163
Practice Address - Fax:770-240-0163
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010240235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist